Anatomy teaching for first year medical sciences students in Liege Medical School, Belgium, s based on both lectures and e-learning. An introductive lesson on anatomical description has been developed on ... [more ▼]

Anatomy teaching for first year medical sciences students in Liege Medical School, Belgium, s based on both lectures and e-learning. An introductive lesson on anatomical description has been developed on e-learning as a tool for description and spatial view training. That first on-line lesson has been constructed by identifying the conceptual requisite to understand anatomy and its specific descriptive language, by dissection and finally by organisation of those requisites to allow generalisation and transfer. The lesson conception gives the students the opportunity to practice the exercise at their own rhythm trough all the steps of the reflective process. That e-learning lesson has been regulated by a follow-up of two years practice in real conditions. This article emphasizes the methodological principles which are the base of the micro graduated structure of the distance course. [less ▲]

The authors report two cases of pelvic lipomatosis associated with glandular cystitis. This is a rare disease with variable and nonspecific clinical features. Complementary investigations useful for the ... [more ▼]

The authors report two cases of pelvic lipomatosis associated with glandular cystitis. This is a rare disease with variable and nonspecific clinical features. Complementary investigations useful for the diagnosis of pelvic lipomatosis are CT and especially MRI, intravenous urography and biopsies. The clinical features, radiological findings and therapeutic approach are discussed in the light of a review of the literature. [less ▲]

Title Inside-out transobturator vaginal tape (TVT-O): One-year results of a prospective study Introduction and Objectives The aim of this study was to prospectively assess the efficacy of a new surgical ... [more ▼]

Title Inside-out transobturator vaginal tape (TVT-O): One-year results of a prospective study Introduction and Objectives The aim of this study was to prospectively assess the efficacy of a new surgical technique, the inside-out transobturator vaginal tape (TVT-O), for the treatment of female stress urinary incontinence (SUI). Study design, materials and methods From 03/2003 through 10/2003, a TVT-O tape was inserted in 83 consecutive patients with clinical evidence of SUI. Preoperative evaluation included complete history, physical examination, urodynamics, urine analysis, and cystoscopy. None of the patients presented the following exclusion criteria: post-void residual (PVR) >100 cc, detrusor overactivity or acontractility, pregnancy, neurological pathology, active urinary or vaginal infection, age >85 years, negative stress test, and maximum cystometric capacity <300 mL. Post-operative evaluation was carried out using symptom scoring and quality of life (QoL) questionnaires, visual analog scales, physical examination, uroflowmetry, and PVR measurement. Cure was defined as no leakage based on both symptom scale scoring and physical examination. Improvement was defined as ≥50% decrease in symptoms based on the questionnaire’s results. Results Mean age of the patients was 61 years. The TVT-O procedure was associated with pelvic organ prolapse cure in 15 patients (18%). Follow-up time was ≥12 months in all women (mean = 13.6); 3 patients were lost to follow-up. No significant blood loss (≥100 cc), vaginal wall, urethral, or bladder perforation was encountered. No hematoma, vaginal or urethral erosion, or neurological complication was observed. No patient complained of persistent pain. At the latest follow-up visit, max flow rate was ≥10 mL/sec and PVR was <100 cc in 90% and 94% patients, respectively. Two patients underwent an immediate tape release procedure while the tape was sectioned in 2 other patients for retention and/or urgency associated with obstruction. Sixty eight patients (85%) were cured of their SUI while 9 patients (11%) were improved. Urgency questionnaire’s results showed that 5 (5/46) patients developed de novo urgency. Twenty and 14 out of the 34 patients with preoperative urge symptoms reported either disappearance or no change of urgency, respectively. Obstruction symptoms appeared or worsened in 3 patients and were unchanged or decreased in all other patients. Analysis of the incontinence visual analog and QoL scale scores showed that the majority of patients reported disappearance of incontinence together with significant improvement of their QoL. Conclusions The one-year results of this study suggest that TVT-O is associated with a low incidence of peri- and post-operative complications and high objective and subjective SUI cure rates. [less ▲]

PURPOSE: We have recently described a novel surgical technique for female stress urinary incontinence, that is the transobturator vaginal tape inside out, which uses specific instruments for the passage ... [more ▼]

PURPOSE: We have recently described a novel surgical technique for female stress urinary incontinence, that is the transobturator vaginal tape inside out, which uses specific instruments for the passage of a synthetic tape from beneath the urethra toward the thigh folds. Herein we report the results of cadaver dissection performed to determine the anatomical trajectory of the tape and its relationships with neighboring neurovascular structures and organs. MATERIALS AND METHODS: Insertion of the transobturator vaginal tape inside out tape was performed by different surgeons in 12 freshly frozen female cadavers according to the standard procedure. The thigh, obturator, perineal and pelvic regions were dissected and tape trajectory was recorded. An additional cadaver was dissected without prior tape placement. RESULTS: The tape was inserted according to a certain consistent path, that is penetration from the suburethral space into a strictly perineal region limited medial and cranial by the levator ani muscle, caudal by the perineal membrane and lateral by the obturator internus muscle. This region corresponded to the most anterior recess of the ischiorectal fossa. The tape then perforated the obturator membrane and muscles, and exited through the skin after traversing adductor muscles and subcutaneous tissue. The tape was coursed away from 1) the dorsal nerve to the clitoris located more superficially below the perineal membrane, 2) the obturator nerve and vessels, and 3) the saphenous and femoral vessels. CONCLUSIONS: These findings strongly suggest that our transobturator technique is highly accurate, reproducible and safe, and it does not require perioperative cystoscopy. [less ▲]

Introduction and Objective: To describe a new, simple surgical technique for the treatment of female stress urinary incontinence (SUI) and to evaluate its feasibility. Methods: We have developed a novel ... [more ▼]

Introduction and Objective: To describe a new, simple surgical technique for the treatment of female stress urinary incontinence (SUI) and to evaluate its feasibility. Methods: We have developed a novel surgical treatment of SUI, the transobturator inside-out tension-free urethral suspension, which uses specifically designed surgical tools: a pair of stainless steel helical passers, two plastic tubes with a pointed distal end and one guide. Using these instruments, a synthetic tape is passed from underneath the urethra, through the obturator foramens, towards the thighs, without entering the pelvic region at any time during the procedure. The tubes bear a lateral opening, which allows the insertion of the helical passer into its lumen. The proximal end of each tube is attached to a non-absorbable synthetic tape. The guide acts as a shoe-horn to ease the introduction of the tubes assembled onto the helical passers from the perineal space through the obturator foramen. After perforation of the obturator membrane, a rotational movement of the helical passer around the upper part of ischio-pubic ramus allows the exit of the pointed tip of the tube and, further, of the tape at the level of the thigh on either side. The tape is positioned without tension under the junction between mid and distal urethra. Results: The procedure was carried out in 210 consecutive patients (mean age = 62 years) using the same operative protocol in all case subjects, independently of the patient’s size and weight. Mean operative time was 14 min (range = 6 to 20) in case of isolated SUI treatment. No bladder or urethra injury and no vascular (hematoma or bleeding) or neurological complication were observed. Conclusions: The results of this study indicate that our novel transobturator inside-out surgical technique for treating SUI is feasible, accurate, and quick. This technique avoids damage to the urethra and bladder and, therefore, makes cystoscopy not necessary. Further prospective studies are currently ongoing to determine the efficacy of our new surgical approach for treating SUI. [less ▲]

Hypothesis / aims of study The aim of this study was to prospectively evaluate the efficacy of the TVT-O inside-out procedure for the treatment of female stress urinary incontinence (SUI). Study design ... [more ▼]

Hypothesis / aims of study The aim of this study was to prospectively evaluate the efficacy of the TVT-O inside-out procedure for the treatment of female stress urinary incontinence (SUI). Study design, materials and methods From March 2003 through September 2003, 53 patients with clinical evidence of SUI participated in this prospective clinical trial. Preoperative evaluation included complete history, physical examination, multichannel urodynamics, urine analysis, and cystoscopy. None of the patients presented the following exclusion criteria: post-void residual volume (PVR) ≥ 100 cc, detrusor overactivity or acontractility, contraindication to anesthesia, pregnancy, neurological pathology, or active urinary or vaginal infection. All patients met the following inclusion criteria: age > 25 and < 85 years, clinically demonstrated SUI, positive Ulmsten test, and maximum cystometric capacity ≥ 300 mL. In all patients, a sub-urethral tape (Gynecare®) was inserted by one single surgeon via an inside-out transobturator approach (TVT-O), as previously described (1). Evaluation of SUI, urgency/urge incontinence, daytime urinary frequency/nocturia, and lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction/retention was carried out using the Measurement of Urinary Handicap scale questionnaire (2). The importance of urinary incontinence was assessed with a visual analog scale graded from 0 to 10. Quality of life (QoL) assessment was performed using the validated Ditrovie self-administered questionnaire. Outpatient follow-up was perfomed at 1 and 6 months, and every 6 months thereafter. Follow-up evaluation included physical examination with a stress test, uroflowmetry, PVR, and symptom, visual analog, and QoL scales scoring. Cure was defined as no leakage based on both symptom scale scoring and physical examination. Improvement was defined as at least a 50% decrease in symptoms based on the questionnaire’s evaluation. Chart review was conducted by a physician not associated with the surgical procedure. The specific protocol used in this study was approved by the Medical Ethics committee of our Institution. All patients had given their written informed consent. Methods, defintions,and units conform to the standards recommended by the ICS. Results Mean age of the patients was 61.2 years (36 to 80). Of the 53 patients, 20 had undergone previous pelvic surgery. Forty-eight patients suffered from SUI. Five patients did not complain of SUI but had clinical evidence of SUI after reduction of pelvic organ prolapse (POP) during vaginal examination. The TVT-O procedure was associated with POP cure (performed before TVT-O) in 12 patients. Maximal urethral closure pressure was < 30 cm H20 in 6 patients. Follow-up time was ≥ 6 months in all women (max = 12.5; mean = 8). A total of 33 and 20 women received spinal and general anesthesia, respectively. Intraoperative blood loss was < 100 cc in all cases. No vaginal wall, urethral, or bladder perforation was encountered. No hematoma, neurological complication, fistula, vaginal or urethral erosion, or tape rejection was observed. Some patients reported pain symptoms, directly after the procedure, mainly located in the thigh regions (either uni- or bilaterally). Pain was always mild, never requiring opioid antalgics. No patient complained of persistent pain; indeed, pain had completely vanished within the first post-operative month in all cases. At the latest follow-up visit, PVR was < 100 cc and max flow rate was ≥ 10 mL/sec in 49 (92.4%) and 39 (73.6%) patients, respectively. One patient underwent an immediate tape release procedure for complete retention 2 days after TVT-O. Thereafter, the patient had no PVR and was completely dry. The tape was sectioned in 2 patients for chronic retention and/or urgency associated with bladder outlet obstruction, 4 and 7 months after the operation. Based on the SUI questionnaire evaluation and physical examination, 50 (94.3%) patients were cured. SUI symptoms had improved in 1 patient and had not changed in another. One patient with POP not complaining of SUI preoperatively (but with clinically demonstrated SUI following POP reduction) developed SUI after POP cure associated with TVT-O. Analysis of the urgency questionnaire’s results revealed that among the 53 patients, 32 did not complain of any urgency before the operation. Of these 32 patients, 3 patients developed de novo urgency, with one of them requiring tape sectioning because of obstruction-associated urge incontinence. Among the 21 patients with preoperative urge symptoms, 15 of them reported disappearance of urgency after the procedure. Urge symptoms were unchanged in the remaining 6 patients. Daytime frequency/nocturia symptoms scale scoring showed that 4 patients had a worsening of these symptoms while all other patients were either improved or unchanged. LUTS suggestive of bladder outlet obstruction/retention appeared or worsened in 3 patients, amongst which the 2 patients who required tape sectioning. These symptoms were unchanged or decreased (mainly in patients with associated POP cure) in all other patients. Analysis of the urinary incontinence visual analog and QoL scale scores demonstrated that the majority of patients reported disappearance of urinary leakage together with significant improvement of their QoL (Figures 1 and 2). Interpretation of results As already suggested by the results of a recent feasibility study (1), TVT-O appears to be associated with a minimal risk of peri-operative complications. Indeed, in our present prospective study, no injury to the bladder, vagina, or urethra was encountered and we have not observed any vascular, digestive or neurological complication. Our data suggest that TVT-O is associated with high objective and subjective SUI cure rates and a low incidence of post-operative complications. Longer follow-up times are required to determine the long-term efficacy of TVT-O. Concluding message The short term results of this prospective study suggest that TVT-O is a safe and efficient surgical procedure for the treatment of female SUI. References 1. Novel surgical technique for the treatment of female stress urinary incontinence: Transobturator vaginal tape inside-out. Eur Urol 44:724-730, 2003 2. Elaboration and validation of a specific quality of life questionnaire for urination urgency in women. Prog Urol 7:56-63, 1997 [less ▲]

in European Journal of Vascular and Endovascular Surgery (2003), 26(6), 657-664

Objectives. Proximity of ureters with iliac arteries makes them prone to damage by aorto-iliac pathology or surgery. The aim of this retrospective study is to analyse the incidence, the predisposing ... [more ▼]

Objectives. Proximity of ureters with iliac arteries makes them prone to damage by aorto-iliac pathology or surgery. The aim of this retrospective study is to analyse the incidence, the predisposing factors, and the optimal treatment Of ureteral stenosis (US) or leakages (UL). Design. Retrospective study. Material. Fiftyone ureteral lesions in 41 patients referred to the urologist in a fourteen years period in the same institution. Methods. Lesions are classified in three groups: A, preoperative; B, less than 3 months postoperatively; and C, more than 3 months postoperatively. Group A comprises 10 abdominal aortic aneurysm (AAA) patients; eight of the AAA are of the inflammatory type. Group B comprises 16 patients, 11 US and 9 UL. Group C comprises 15 patients and 15 US. Results. Endoureteral treatment was successful in most of the group B patients. Some of them, however, had to be submitted to secondary open surgery, so that the global success rate is 70% in group B. In group C, the response is poor following endourological treatment alone (12.5% success) and open surgery is more often needed (3 ureterolyses and 1 nephrectomy). Global success rate is 40%. Conclusion. Early diagnosis is associated to better results with less invasive procedure, late diagnosis is accompanied by a lower success rate of endourological treatment and requires more often primary open surgery. [less ▲]